trauma mechanism of injury injury patternsages 1-44 years 140,000 ... fx ribs, pulmonary contusion,...

Trauma Mechanism of Injury

& Injury Patterns

South Cook County EMS

February, 2016

EMS Solutions ems-safety.com

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Mechanism of Injury

Trauma Systems & Mechanism of Injury

Epidemiology Trauma is the leading cause of death for

ages 1-44 years 140,000 unexpected deaths per year Automobile related > 40,000 Penetrating trauma to exceed blunt in

near future

Energy

Physical Laws Newton’s first law of motion

A body in motion remains in motion / rest until acted on by outside force

A vehicle traveling 50MPH, occupant traveling at 50MPH

Vehicle stops, occupant continues until acted on by outside force

Conservation of Energy Energy cannot be created or destroyed Can be changed in form Energy must be absorbed resulting in deformity of

substance

Energy Law Summary

Motion is created by force (energy exchange) Force (energy exchange) must stop

this motion If such energy exchange occurs inside

the body, tissue damage is produced

Energy Exchange

Interaction between two bodies At least one must be in motion Both can be in motion

Dependant on number of particles involved in the interface of the interaction Density of the interacting bodies

History (of the incident)

Thorough history will identify 95% of injuries

Incident site Known “Bad Locations”

Major factors of tissue injury What forces were applied?

Amount of energy exchanged Speed of vehicles

Anatomical structures potentially involved

Don’t get Tunnel Vision

The leg looks nasty…but is it fatal to him right now?

Keep Assessment Focused This injury does not

look as bad…but may become fatal

Trauma Systems

Components of a Trauma System: Injury pattern Prehospital care Emergency department care Interfacility transfer Definitive care Trauma critical care Rehabilitation Data collection – trauma registry

Transport Considerations

Level of receiving facility Mode of transport Ground transport If appropriate facility can be reached in

reasonable time (Level 1 – 25 min, Level 2 – 30 min) Transport to nearest ED if transport time > 30

Air transport Indications – time frame, # of patients, etc. Contraindications – weather, landing site, etc Procedure – call time, flight time, etc.

Guideline: Entry into Trauma System

Physiological

Systolic BP < 90 With findings of hypoperfusion Suspected etiology

Respiratory Distress Rate < 10 or > 29

Altered Mental Status GCS < 10

Anatomical

Flail Chest Two or more long bone fractures

Humerus, femur Penetrating injury to head, neck, torso or abdomen

that is associated with significant energy transfer Amputation proximal to the wrist or ankle Paralysis of any limb associated with trauma injury Combination trauma with >20% total body surface

Mechanism

Maternal trauma > 24 weeks Death of any occupant in the patient’s

vehicle Ejection of patient from an enclosed

vehicle Falls > 20 feet Falls > 3x the body length of a child

Co-Morbid Factors (which may be considered)

Age < 12 or > 60 Pregnancy Significant preexisting medical

problems Extremes of environment Hot or cold

Presence of intoxicants (etoh, etc)

Index of Suspicion

Any patient who, in the judgement of prehospital personnel, would benefit from transport to a trauma center.

Mechanism of Injury

Types of Trauma

Blunt Tissue not penetrated Cavitation away from site of impact Cavitation in direction of impact

Penetrating Tissue penetrated Cavitation at 90° to bullet pathway Tissue inline penetration is crushed

Blunt Trauma

Vehicle collisions Frontal Lateral Rear Rotational Roll over

Frontal Impact

Up and over Body travels up and over steering wheel

Down and under Body travels down and under steering wheel

Common injuries seen in frontal impacts may be: Up and Over – Rib fractures, hemo/pneumothorax, cardiac contusion, aortic rupture. Down and Under – Knee dislocation/fx, femur dislocation/fx, pelvic fx.

Frontal Impact

Lateral Impact

Vehicle struck on side Vehicle moves into and impacts body Occupant forced away from collision

point Lateral injury pattern: Examples- Fx ribs, pulmonary contusion, ruptured liver or spleen (depending on side involved), head, neck injuries.

Lateral Impact

Rear Impacts

Vehicle struck in rear Occupants in direct contact with vehicle will

move also The force of the energy exchange depends on

the differential energy of the two vehicles Secondary impact as vehicle strikes another

object Predictable injuries may include: head, neck, back strain or fx due to hyperextension.

Rear Impact

Rotational Impacts

Pure rotational, one part of vehicle hits an immovable object while the rest continues in motion

Remainder of vehicle moves around the fixed position

The motion of the occupant is a combination of two motions Frontal & Lateral Rear & Lateral

The injuries are combinations of the two motions

Rotational Impact (may see same injury pattern as lateral and rotational incidents)

Roll Over

Vehicle and occupant roll over Difficult to predict injury pattern /

body impacts Can include all types of impacts Roll Over vs. “Turn Over”

Roll Over

Consider the Force Involved

Ejection

If the force is such and the occupant is unrestrained, eject can result The major injuries occur inside the

vehicle and on the way out Think of the first part of the collision

rather than the latter portion

Motorcycle Collisions Frontal Bike stops Occupant

continues forward Impacts parts of the

bike Ejected over the

bike Injuries

C-spine Torso Compound tib/fib

Motorcycle Collisions Angular Collapse of bike onto vehicle Lateral motion of torso into vehicle Injuries – “crush” type on affected side Torso Lateral chest Lateral abdomen Aorta Pedicled organs

The Real Collisions

Organ Collisions

Two types of injury from blunt trauma result from: Compression Change in velocity Acceleration Shear Avulsion

Deceleration Shear Avulsion

Organ Collisions Head Organ collisions with different

vehicular collisions Head Compression (fx skull, cerebral

contusions) Deceleration Opposite end separation Hemorrhage Brain stem stretch

Organ Collisions Neck Neck Compression Vertebral body Compression fx Hyperextension injury Hyperflexion injury

Shear Spinal cord

Organ Collisions Thorax Thorax Chest wall Compression (rib fractures, pneumothorax) Shear (fractured thoracic spine) Tx for pneumo – chest decompression

Heart Compression (contusion, rupture) Shear

Aorta Compression Shear (very bad….)

Organ Collisions Lung Lung Compression Pneumothorax Rib fracture and penetration

Shear “paper bag effect” – deep breath prior to impact, impact causes change in lung pressure, alveoli rupture, air escapes into pleural space

Organ Collisions Abdomen Abdominal cavity Diaphragm Abdominal wall

Liver Compression (burst type injuries) Shear (ligamentum tears) avulsion

Spleen Compression (burst) Shear (avulsion of pedicle)

Organ Collisions Abdomen

Gastrointestines Compression (rupture) Shear (avulsion of mesenteric vessels)

Gallbladder Compression (rupture) Shear (avulsion from liver) Remember, severe abd injuries usually have orthostatic BP changes, patient may be pale, nauseated and dizzy

Organ Collisions Pelvis Compression Impact on the femur Femoral head driven through acetabulum Fracture of the ileum Sacro-illiac joint fracture Fracture of other bones in the pelvis

Restraints

Systems designed to absorb the energy before the occupant hits something hard and limiting the distance the body travels Lap belts Shoulder restraints Air bags Child safety seats

Restraints

They could cause injury

Injury could be missed without proper assessment

Mentation / LOC Assessment

A-Alert Able to answer questions

V-Verbal Responds to verbal stimuli

P-Pain Responds only to pain stimuli. Protect airway

U-Unconscious Protect airway, consider intubation

Other Injuries

Factors Height Surface of impact Objects struck during decent

Feet first Impact onto calcaneous Continued motion of the torso Ankles, knees, femur, pelvis, spine, torso

Head first Compression Skull fracture Brain Spine

Deceleration Aorta Kidney Other

Deceleration

Dislocated fracture of spine from feet hitting ground first

What other orthopedic injuries would be expected?

Penetrating Injuries

Cavitation Permanent

Visible when examine

Crushed tissue Temporary

Compression wave of tissue particles

Away from the pathway of the bullet

Last only a few microseconds

Tissue damage produced by stretch

Density

Lung (Hollow) Air Liver (Water)

Bone (Solid)

Penetrating Injuries Anatomy

Organs injured Pathway of missile Entrance wound Hole is crushed forward Round or oval shaped Rim, abrasion, burn

Exit wound Pushed outward Stellate or slit

Gunshot to Head

External affects

CT of same wound

trauma mechanism of injury injury patternsages 1-44 years 140,000 ... fx ribs, pulmonary contusion,...

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